Your appointment date *

Title

Surname (family name) *

First names *

Preferred name (if different from first name)

Gender *

Date of birth *

NHI (Hospital) number (if known)

Street address and postcode *

Postal address and postcode (if different from street address)

Home phone number

Work phone number

Mobile phone number

Email Address *

Occupation

Next of kin (and relationship) *

Next of kin phone number *

Family doctor (GP) *

Enter NIL if no GP

GP practice name *

Suburb at least please. Enter NIL if no GP

Preferred pharmacy (include pharmacy street address please) *

This allows us to deliver your prescription electronically to your local pharmacy

Medical insurance? *

Southern Cross member? *

nib member? *

Who is your medical insurance provider? *

Southern Cross policy number *

nib policy number *

What is the main reason for your appointment? *

Spots / moles
Skin check
Rash
Other

Please provide further details on your answer above *

How long have you had this problem? *

Days
Weeks
Months
Years

What parts of the body are affected? (choose all that apply) *

Scalp / face
Trunk
Arms / hands
Legs / feet

What makes it feel better and what makes it feel worse?

How much does the problem bother you? *

Not at all
A little
A lot
Very much

Is your problem: *

Worsening
Stable
Improving
Not relevant

Please explain your answer above

Have you seen a doctor for this problem? *

List all the treatments you have tried and if they helped or not

Please bring these treatments with you

Previous skin cancers? *

Please specify regarding your previous skin cancers

Is there a family history of a condition similar to yours? *

Please provide more information regarding this

Any other symptoms that could be relevant?

Past skin problems *

Details please, include medications used, or enter “NIL"

Current or past medical problems and operations *

List, or enter “NIL"

Current medications *

Please list, or enter “NIL"

Medication allergies *

Please list, or enter “NIL"

Likely to need surgery? *

If you think there is a chance your skin condition will require surgery please answer “Yes

Select all that apply:

I have bleeding problems, excessive bruising, or post-surgical bleeding

I take blood thinners (aspirin, warfarin, clopidogrel, dipyridamol, dabigatran etc)

I take fish oil, ginko, vit E, ginseng, dong quai, feverfew, reservatrol, or garlic supplements

I have a pacemaker or implantable defibrillator

I have had joint surgery, artifical heart valve, or heart stent surgery in the last 12 months

I have had an infection following skin surgery

I take medications that suppress my immune system

I have diabetes

I am a current smoker or past-smoker

Other source of finding us

Tick the category that best applies *

NZ or Australian citizen permanently living in NZ
Resident class visa or work visa valid for 2ys or more
Neither

Helps determine if you are likely to be eligible for public funding of blood and lab tests if required. For more information see: https://www.labtests.co.nz/wp-content/uploads/sites/2/2019/11/4.2-Test-funding-eligibility.pdf

Click to attach referralMax file size 50Mb

You may attach your referral letter, photos, or relevant biopsy or lab test results

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